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Home > news > Client Success Story – M.L. (Hospital-to-Home Rouge Valley Centenary)

M.L.’s Story (as told by Community Mental Health Worker Shiraz Nurradin)

M.L. is a 63 year old woman who was admitted to inpatient psychiatry at Rouge Valley Centenary on August 4th, 2015 and discharged October 30th, 2015. She had a few previous admissions and has a history of admissions to The Scarborough Hospital also. M.L. faces multiple diagnoses: major depressive disorder, schizophrenia, panic disorder and borderline personality disorder. She lives on her own in Toronto Community Housing (TCH) and has a cat. Her sister Pam is involved with her care.

When I received the referral, Pam had been expressing concerns about the apartment not being well kept. I called TCH Resident Access and Support and was connected with TCH’s Community Service Coordinator. I met with the Community Service Coordinator, Pam, the building superintendent and M.L. at M.L.’s apartment to assess and plan before discharge.

The unit was cluttered and messy. Pam hired and paid for a cleaner to properly clean the unit. TCH’s Community Service Coordinator was in contact with me throughout the whole process and TCH even replaced the fridge the day of discharge.

I also contacted TCH’s Assisted Living and Home Support Manager at M.L.’s building. The Assisted Living and Home Support Manager offered M.L. three contacts daily: one security check and two visits to assist with medication every day. She also looked into getting a Personal Support Worker (PSW) once a week. M.L. was also referred to Community Care Access Centre (CCAC) to get her into long term care. Meals on Wheels service was also arranged.

The plan was that the TCH Assisted Living program would check on M.L. and provide medication daily and Meals on Wheels would provide for dinner. Pam was to visit M.L. a minimum of once a week and provide her with a little cash.

On M.L.’s discharge day I drove her to her home and met with her, Pam, TCH’s Community Service Coordinator, TCH’s Assisted Living and Home Support Manager, the building manager and PSW Lillibeth. M.L. and her sister were introduced to all of the members of our team.

I received a recent call from CCAC informing me that M.L. is currently receiving Occupational Therapy. CCAC assessed M.L. for long term care and decided that at the moment she does not qualify for long term care and is able to care for self.

I am happy to report that M.L. has managed well in the past few months at home.

I think that without DMHS involvement and without the collaborative partnerships between DMHS and all of the other organizations involved, M.L. could not have stayed at her current home. I am glad to have been involved in her care. It is great to see her make the transition from hospital to home. In her case, we involved all areas of housing to have her home cleaned and made conducive to her mental health. RVC nurses and her psychiatrist still ask me about her and they are pleased to know that client is doing well at home and is well supported.

“The successful outcome and improved experience for M.L. clearly illustrates what can be achieved when health and social service providers work with clients and their caregivers as an integrated system. DMHS, along with their hospital, housing and support services colleagues, are making a difference in the lives of M.L., Pam and hundreds of other people each and every day and supporting the LHIN’s strategic aim of helping people to live healthier lives in their homes and communities.”

Deborah Hammons, CEO, Central East LHIN